Non- Pharmacological Approaches on the Improvement of Sleep Disturbances in Patients with Autism Spectrum Disorder (ASD)

Abstract Autism is a type of neurodegenerative disorder, caused by genetic and environmental factors. Children with autism spectrum disorder (ASD) have symptoms of attention deficit and behavioral problems. Child’s sleep pattern has a significant effect on mood. Sleep problems are more common in children with ASD. The current study aimed to investigate the effect of non-pharmacological approaches on the improvement of sleep disturbances in patients with ASD. Materials & Methods We systematically searched PubMed, EMBASE, Web of Science, Scopus, and Science Direct to identify relevant articles published from January 2009 to May 2019. All original articles from observational and interventional studies were reviewed. The CONSORT Statement and Strengthening the Reporting of Observational Studies in Epidemiology(STROBE) checklist were used to assess the quality of selected papers. Results Reviewing 18 eligible articles according to the CONSORT checklist(for interventional studies) and STROBE (for descriptive studies) demonstrated that behavioral interventions, such as cognitivebehavioral therapy, bedtime fading with response cost, and functional behavioral assessment, physical activity such as aerobic exercise, swimming, and aquatic exercise and weighted blankets can improve sleep disturbances. Conclusion: Restlessness, tantrums, increased stereotypic activities, and reduced learning level and speaking power in children with autism were. caused by poor sleep quality and sleep deficiency, which may affect other dimensions of life. Non- pharmacological approaches to sleep disturbances could improve both sleep quality and quality of life of children with ASD with no adverse effect.


Introduction
Autism is characterized by difficulties in social interactions and communications and a tendency to engage in repetitive behaviors (1). Several genetic and environmental factors contribute to this neurodevelopmental disorder (2). Autism Spectrum Disorder (ASD) is most likely to be affected by social-cognitive impairments and has a distinct brain structure and function (3).
Children with ASD present symptoms of deficits in attention, social skills, and behavior (4). New and North America is around 5% (5). Also, boys are four times more likely to develop ASD than girls. More than 75% of ASD cases are linked with other neuropsychiatric disorders, which may increase the complicacy of diagnosing the disease (6). ASD usually appears in a child's first 3 years of life (mostly 18 to 24 months); therefore, the definitive diagnosis is also around this period (7).
The increased incidence of ASD indicates the need for efficient, sensitive, and targeted tools to assess the disease (8). As ASD is a spectrum disorder, it can be treated using various therapeutic options, including pharmaceutical and non-pharmacological approaches for managing autism-related problems.
The appropriate therapeutic option should be chosen based on the child's needs, with special attention to reducing symptoms, enhancing learning, and promoting development. Currently available approaches to treat ASD contain pharmaceutical treatments, complementary therapies, and behavioral and communication treatments (9,10).
Most of the ASD children (38-44%) suffer from sleep disturbances. Other common sleep disorders include sleep latency, restless sleep, and waking up frequently during the night (11). Therefore, there are many therapeutic approaches to improve sleep disturbances.
Children with autism need treatments with high flexibility. Cognitive Behavior Therapy (CBT) is a commonly used targeted strategy to adapt patients with autism to adaptive patterns of thinking and behavior, that results in positive changes in feelings and reduced functional impairment (12). The CBT is used as a therapeutic approach to behavioral  (15). Weighted blankets also influence sleep quality (16). There are systematic reviews, with explicit and explicit goals, which have summarized the reported outcomes as well as the best form of evidence for judgment (17) (16). Systematic reviews can summarize reported outcomes by several studies and provide the highest form of evidence for scientific judgment (17). According to the best knowledge of the authors, no systematic review has investigated the effects of non-pharmacological approaches on improving sleep disturbances in patients with autism. Therefore, the results of this study can help make decisions about the prescription of alternative therapies, instead of drug therapy, with lower risks.
The current study aimed to investigate the effect of non-pharmacological approaches on improving sleep disturbances in patients with ASD.

Search strategy
The present study is reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched MEDLINE, Web of Sciences, PubMed, Scopus, Google Scholar, and ProQuest to identify relevant articles published.

Inclusion and exclusion criteria
The inclusion criteria were as follows: (1) All Persian

Study selection
Initially, 422 studies were found. The eligibility of articles was independently evaluated by two researchers, and disagreements were resolved by consensus. In the first stage, 213 articles were excluded due to being irrelevant or duplicated. After reviewing the titles and abstracts of the remaining articles, 86 were excluded. After evaluating full texts, 74 (out of the remaining 123 articles) were excluded due to not matching inclusion criteria.

Quality assessment
The CONSORT (Consolidated Standards of Reporting Trials) and STROBE statements were used to evaluate the quality of studies. The CONSORT Statement is a 25-item checklist, which is focused on reporting how the trial was designed, analyzed, and interpreted. STROBE Statement is an authoritative tool consists of a 22-item checklist, which is focused on reporting or evaluating different sections of observational studies (18,19).

Data extraction
Two authors independently evaluated the articles.
In case of disagreement, a consensus was reached through discussion. The first author name, publication year, country, study design, sample size, age, quality assessment, and results were extracted and entered the analysis.

Results
The search process used in the present study is presented in Figure 1. First, the titles and abstracts of the articles were reviewed. The full texts of the articles which had inclusion criteria were reviewed.

Discussion
This study demonstrated that behavioral therapy and physical activity, as non-pharmacological approaches and effective therapies, not only could improve sleep disturbances in individuals with ASD, but also no side effect was observed. Besides, administering these approaches was associated with improved quality of life of ASD patients.

States to investigate the effect of CBT in adolescents
with autism and demonstrated that, based on Clinical Global Impression-Improvement (CGI-I), those who received this treatment presented a better improvement rate than those in the control It worth noting that this study was conducted on a small sample size that was appropriate for assessing the feasibility of this measure, but caution should be taken when generalizing the results (37).
In addition to the above-mentioned results, they reported that sleep disturbances in individuals with autism who received CBT were also improved,

In Conclusion
This study demonstrated that the severity of autism spectrum disorder or ASD may range from mild to severe, and the disease is characterized by mental